Current Thinking on Subtalar Joint Arthroeresis
In his lecture at the NYSPMA Clinical Conference, Allen Jacobs, DPM, relates that subtalar joint arthroeresis has been used for over 40 years, blocking anterior/inferior talar migration. He points out that once the original implant was approved, FDA approval of additional “substantially equivalent” implants takes place via the 510K process, so he encourages surgeons to know specifics about the implant under consideration.
He went on to review historic subtalar arthroeresis procedures, from Grice to Lelieve, including the Grice-Batchelor procedure. The Chambers osteotomy, he says, elevated the floor of the sinus tarsi so the lateral process ends pronation sooner. Later, an arthroeresis implant was developed with that same goal.
Regarding the features of subtalar joint arthroeresis, Dr. Jacobs reminds the audience that it is primarily for valgus heel deformity and lateral column stabilization with control of the subtalar joint. The plan is typically to remove the implant once skeletal growth is complete, he says, and he notes a recent enthusiasm for use in adult deformity. Dr. Jacobs shares that many frame subtalar arthroeresis as an “internal orthotic,” reversible, usable with adjunctive procedures, and temporizing until maturity. He adds that the procedure may potentially avoid need for osteotomy or arthrodesis.
During evaluation prior to deciding upon a subtalar joint arthroeresis, Dr. Jacobs stresses the importance of testing for midtarsal joint abduction, as its presence may indicate a requirement for additional procedures. He also assesses for “too many toes sign” and does a comprehensive radiographic evaluation.
Touching on classifications, he shares that the Vogler classification separates these arthroereses into self-locking wedges (the majority of implants), axis-altering devices, and impact blocking devices.
Dr. Jacobs commented that he has noted some expanding use of this procedure, including more in adult patients, and even sometimes in Charcot reconstruction.
He cites potential complications associated with subtalar arthroeresis including undercorrection, overcorrection, extrusion, impleant wear, synovitis, loosening, erosive/cystic bone changes, and chronic pain.
After reviewing available practice guidelines for this procedure, he encourages the audience to use it judiciously and with caution. He stresses that this is not a procedure to apply universally, and that one should consider any need for adjunctive intervention and monitor for sequelae following surgery.
